FULL Neurotoxic Questionnaire

Name:
Date:

MonthDayYear
Date
Address:
Unit:
City:
State:
Zip:
PHONE
Home:
Mobile:
Work:
Email Address:
example@example.com
Date of Birth:

MonthDayYear
Date
Gender:

MaleFemale
Age:
Height:
Weight:
Status:

MarriedWidowedSpouseChildrenSeparatedSinglePartnerFriendsDivorcedPartnershipParentsAlone
Education:
Occupation:
Hours per week:

Retired
Hours per week:
Employer
Work Address
In case of emergency, whom should we contact? NameRelationship
Name
Relationship
Address
Phone
How did you hear about our Wellness and Nutrition Program?
What is your major complaint. Please List when each symptom began and be as descriptive as possible
Revelation Health 2013; All Rights Reserved
What are your current medications?
What are your current vitamins and/or supplements?
What are your current vitamins and/or supplements?
Please list your current and past health conditions (i.e. Diabetes Mellitus, etc
Is there anything else in your medical history that you consider to be relevant? (Even from childhood)
What is your employment history? Please provide brief summary including dates if possible.
Please list past or present allergies, including allergies to medications.
Please list all past surgeries and the condition each surgery was for, including dates.
Please explain your housing history (type of homes, where and when).
Patient History
Mercury
Do you have amalgam (silver) fillings in your teeth?

YesNo
If yes, How many?
Have you ever had an amalgam removed?

YesNo
If yes, How many?
If you had amalgams removed, was it done by a biological dentist using a safe protocol?

YesNo
Did your mother have amalgam when pregnant with you?

YesNo
Have you ever worked in a dental office?

YesNo
If so, How long?
Have you had any dental crowns?

YesNo
If yes, How many?
Have you had any bridges?

YesNo
Have you had any root canals?

YesNo
Have you had any tooth extractions?

YesNo
Do you have any dental implants, retainers or other metal in your mouth?

YesNo
...Explain:
Did you wear contact lenses during the 1980’s or early 1990’s?

YesNo
Did you take oral contraceptives during the 1980’s or early 1990’s?

YesNo
Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

YesNo
Have you noticed any adverse reactions to these shots?

YesNo
Do you have any tattoos with red ink?

YesNo
Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

YesNo
Lead
Does your occupation involve soldering or metal salvage?

YesNo
Have you done any old home repair or sandblasting?

YesNo
If so, When?
Do you do a lot of painting?

YesNo
Was your home built before 1978?

YesNo
Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

YesNo
Are you around a lot of fake leather, or vinyl?

YesNo
Do you get stomach aches in the morning?

YesNo
General Toxicity
Have you ever lived near, on or by a golf course, freeway or tension wires?

YesNo
Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

YesNo
Do you have your house sprayed with pesticides for pest control?

YesNo
Do you spray herbicide (weed killers) in or around your home?

YesNo
Do you use conventional insect repellants on your self or family?

YesNo
Do you use conventional sunscreen?

YesNo
Do you use conventional perfume or cologne every day?

YesNo
Do you get your hair colored?

YesNo
If so, is it on the scalp?
Do you use aerosol hairspray?

YesNo
Do you get your nails done?

YesNo
If so, how often?
Do you use air freshener in your house, work or car?

YesNo
Do you drink filtered water?

YesNo
If so, what type of filter do you have?
Do you drink bottle water if so what kind?

YesNo
If so, what kind?
Do you have a water filtration system for your entire house or shower filtration?

YesNo
If so, what type?
Does your spouse or other family members work around chemicals?

YesNo
Can you think of any other toxic exposures you may have had?

YesNo
Mold
How old is the house you are living in?
How long have you lived there?
Have you noticed any new symptoms since moving in?
If so, what?
Do you see mold growing at home, work or school?

YesNo
Have you ever had water damage at home, work or school?

YesNo
Does your home, workplace or school have a damp or mildew smell?

YesNo
Does spending time in your basement cause or worsen your symptoms?

YesNo
Does your basement ever get wet?

YesNo
Do you have a crawl space?

YesNo
Does your basement or crawl space have a sump pump?

YesNo
Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?

YesNo
Does your car have a mildew smell?

YesNo
Does anyone in your home have asthma like symptoms?

YesNo
Does anyone in your family have chronic sinus infections or irritations?

YesNo
Lyme Disease
Have you ever been diagnosed with Lyme Disease?

YesNo
Have you had dry sockets or infected tooth extractions?

YesNo
Do you have small joint pain?

YesNo
Have you ever been bitten by a tick or recluse spider?

YesNo
Have you ever seen a bulls-eye rash appear on any part of your body?

YesNo
Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?

YesNo
Was your mother ever diagnosed with Lyme Disease?

YesNo
Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

YesNo
Health History
Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

YesNo
Does anyone in your family experience similar symptoms to yours?

YesNo
What is your birth order (i.e. first born, second, third, etc.)?
Do you have any history of kidney dysfunction?

YesNo
Do you or any immediate family member have a history with cancer?

YesNo
Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

YesNo
Are you currently having any thoughts of suicide?

YesNo
Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?

YesNo
Do you have a history of strokes?

YesNo
Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

YesNo
Have you ever been in an auto accident, fallen or received a major physical injury?

YesNo
Are you in menopause?

YesNo
Microbiome Health
Do you get foul or sulfur smelling gas (distention, bloating, belching, feeling full and a noisy gut) after eating carbohydrates (ie. grains and vegetables) or fermented foods and/or probiotics?

YesNo
Do you often have gas that has a sulfur or foul smell?

YesNo
Are you sensitive to supplements?

YesNo
Have you ever been vegan or vegetarian for any length of time?

YesNo
Can you tolerate Meat?

YesNo
Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

YesNo
Have you taken birth control or Hormone replacement therapy for any length of time?

YesNo
If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

YesNo
Have been on antibiotics for any extended period of time or often as a child or adult?

YesNo
Were you caesarian delivered?

YesNo
Were you breast fed?

YesNo
If so, how long?
Does your gut temporarily feel better after a round of antibiotics?

YesNo
How many times a day are you having a bowel movement?
Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank.
Point Scale
0 = Never had the symptom 1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect 3 = Frequently have it, mild effect

4 = Frequently have it, severe effect
Column #1
Anxiety
Mood swings
Enraged behavior or anger for no reason
Excessive shyness, timidity, social phobia (not typical to your personality)
Irritability (not typical to your personality)
Low body temperature (below 97.5)
Insomnia (can’t get to sleep or return to sleep
Dizziness
Sound in ears (ringing or hearing your heart beat)
Psychological symptoms, even thoughts of suicide
Sensitivity to sound
Indecisiveness
Feeling of being overwhelmed or fearful
Metallic taste in your mouth
Bad breath
Bleeding gums
Sensitive teeth
Canker sores or other sores in the mouth
Floaters, shadows or swimmers when you read or look into the sky
Swelling eyelids
Peeling on top layer of skin (hands, feet)
Dry skin
Heart pain (angina) and you are under 45 years old
Depression
Gout (arthritic pain, especially in big toes)
Pain in shoulders or upper back
Twitching eyelids
Anemia (low iron/hemoglobin on blood test)
Wrist/ankle drop or weak extensor muscles
Hair falls out (not normal male pattern baldness)
Column #2
Sensitivity to light
Fatigue after exercising (feeling worse)
Bad night vision or seeing halos around lights
Shortness of breath, with very little effort
Excessive thirst and/or frequent urination
Red eyes or tearing
Blurred vision at times
Morning stiffness
Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners
Chronic fatigue or weakness
Non-restful sleep
Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)
Trouble processing new information
Word reversal or trouble finding words
Sensitivity to touch
Short-term memory loss
Chronic sinus congestion
Dry non-productive cough
Muscle twitching
Excessive sweating, especially at night
Joint pain-not necessarily true arthritis-can move from joint to joint
Difficulty losing weight regardless of diet or exercise
Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis
Frequent illness, prolonged illness or sick days
Numbness or weakness in arms and legs
Headaches
Trouble adding or dividing numbers in your head
Fluctuating constipation and diarrhea
Stomach pain for no apparent reason
Appetite swings
Frequent muscle aches, cramps, unusual sharp sudden pains
Rashes or rosacea
Cold extremities (hands and feet)
Total Columns 1 & 2
Should be Empty:

Patient History

Mercury

Lead

General Toxicity

Mold

Lyme Disease

Health History

Microbiome Health

Point Scale

Column #1

Column #2